BUCK NEL L U NIV ER S ITY

Student Health
Medical Forms
This form must be printed, completed in English in its entirety and the original sent to:

Bucknell Student Health

One Dent Drive
Bucknell University
Lewisburg, PA 17837

No later than June 15 for fall enrollment or January 3 for spring enrollment. Failure to
comply will prevent students from obtaining a dorm room key upon arrival.
Please keep a copy of this completed form for your records.

All VARSITY ATHLETES will be sent an additional ATHLETIC MEDICAL FORM that also must be
completed and returned to the ATHLETIC DEPARTMENT.

All DOMESTIC STUDENTS are required to enroll or waive the Bucknell Student Health Insurance plan
online. This form is not a waiver. Postcards will be mailed in early summer with instructions.

During the summer months, inquiries regarding the medical record are received weekday mornings
after 8:30 a.m. at 570-577-1401. The office is closed during the afternoon.

Bucknell Student Health

One Dent Drive
Lewisburg, PA 17837
Phone: 570-577-1401
Fax: 570-577-3570

A Joint Venture of Evangelical-Geisinger Health, LLC

Rev. 5/2017
 DIRECTIONS FOR PREPARING AND RETURNING THE
BUCKNELL STUDENT HEALTH MEDICAL RECORD

A. DEMOGRAPHICS PRINT CAREFULLY IN INK information requested. Also PRINT your name on all pages where indicated.

B. PART I MEDICAL HISTORY Ask your parents, guardian, or family physician to assist in completing this section.

C. PART II CONSENT FOR TREATMENT SIGN and DATE (signature of parent/legal guardian necessary if student is under age 18).

D. PART III IMMUNIZATION RECORDS Complete (with the assistance of your physician, if necessary) all information
requested on the form. A copy of vaccine records from your medical provider should be included.

REQUIRED IMMUNIZATIONS:

1) Hepatitis B: A 3-shot series is required. The first of three (3) must have been given prior to enrollment at Bucknell. The series
must be completed within one (1) year. (There must be at least four (4) weeks between doses 1 and 2 and at least eight (8) weeks
between doses 2 and 3. Overall there must be at least four (4) months between doses 1 and 3.) A blood test showing immunity will
be acceptable by providing lab reports.
2) Measles, Mumps, Rubella (MMR): Two (2) single doses of live measles (rubeola), mumps, and rubella vaccine or two (2) combined
doses of MMR vaccine at least 28 days apart after 12 months of age and since 1981 are required. A blood test showing immunity
to measles, mumps and rubella will also be acceptable by providing lab reports. Having had the diseases diagnosed is not
sufficient.

3) Meningitis (Meningococcal vaccine A,C,Y, W-135): you must either check the box indicating you have had the vaccine since
August 2014 and enter the date of the vaccine OR check the box indicating you have declined the vaccine. The students
signature (or parent/legal guardians signature if the student is under age 18) is required no matter which box is checked.
Meningitis B vaccine is not required but is recommended.

4) Polio (OPV or IPV): Dates of basic series and last booster (administered at least one year following completion of basic series and
after age 4).

5) Tetanus/Diphtheria/Pertussis (TDAP) or Booster: A TDAP vaccine since August 2007 is required. TDAP may be administered
regardless of interval since the last tetanus or diphtheria toxoid-containing vaccine.

6) Chicken Pox (Varicella): Requirement is: history of having the disease; or two (2) doses of vaccine (the second dose at least 12
weeks after first dose if administered between ages 1-12 years or at least 4 weeks after first dose if administered at age 13 years
or older); or blood test report showing immunity.

E. PART IV PHYSICAL EXAMINATION Arrange for a physical examination (requirement is for a physical within one year
prior to your first day of class at Bucknell) and have PART IV completed and signed by the physician or medical provider
after reviewing the immunization requirements listed above. PLEASE SHOW THIS INSTRUCTION SHEET TO YOUR
PHYSICIAN OR MEDICAL PROVIDER.

F. PART V TUBERCULOSIS SCREENING QUESTIONNAIRE Page 1 to be completed by student and reviewed by Medical
Provider. Provider to complete and sign Part V Page 2 only if student answered yes to Part V Page 1. Part V Page 2 TST interpretation
should be based on mm of induration as well as risk factors.

G. INSURANCE INFORMATION Complete the form and attach a copy, front and back, of your health insurance cards.

H. Return the entire completed medical form to Bucknell Student Health no later than June 15 for fall enrollment or January 3 for spring
enrollment. YOU WILL NOT BE ABLE TO OBTAIN YOUR DORM ROOM KEY IF YOUR MEDICAL RECORD IS
NOT RECEIVED OR IS INCOMPLETE.
 This form must be completed in English in its entirety and the original sent to Bucknell Student Health,
Bucknell University, Lewisburg, PA 17837 no later than June 15 for fall enrollment or January 3 for spring
enrollment. Failure to comply will prevent student from obtaining your dorm room key.

Bucknell Student Health

Lewisburg, PA 17837 During the summer months, inquiries regarding the medical record are received weekday mornings
Phone: 570-577-1401 after 8:30 a.m. at 570-577-1401. The office is closed during the afternoon.
Fax: 570-577-3570

DEMOGRAPHICS STUDENT
Year of entrance ______ Admitted as a First-Year Transfer Graduate Other BU ID#_______________________________________

PLEASE PRINT NAME LEGIBLY IN INK

FULLNAME OF STUDENT_________________________________________________________________________________________________________
Last Name First Name Middle Name

HOME ADDRESS ________________________________________________________________________________________________________________

Street Address

_______________________________________________________________________________________________________________________________
City State / Zip Code

Student Cell Phone ( _____ ) ______________________ Home Phone ( _____ ) ______________________ D.O.B. ________/_________/_________
Month Day Year

Name of Parent/Guardian ___________________________________________________ Parent/Guardian Cell Phone ( _____ ) __________________________

PART I MEDICAL HISTORY STUDENT

No Yes (specify) Remarks or additional information (use additional sheet if necessary)
Have you been diagnosed with ADD/
ADHD?
Are you presently being treated for any
condition?

Do you have a history of asthma?

Do you have a history of diabetes?

Have you ever had a concussion?

How many?

Have you ever received treatment for any

psychiatric, mental health, disordered
eating or psychological condition? Explain.

PART II CONSENT FOR TREATMENT STUDENT

Act 10 of the General Assembly of the Commonwealth of Pennsylvania was approved February 13, 1970, stating: Any minor who is eighteen years of
age or older, or has graduated from high school, or has married, or has been pregnant, may give effective consent to medical, dental, or health services
for himself or herself, and the consent of no other shall be necessary.

My signature below indicates that:

I consent to medical and nursing treatment by the Bucknell Student Health staff.
I am aware of the Notice of Privacy Practices available at: www.bucknell.edu/HealthPrivacy
The information on this form is correct and complete to the best of my knowledge.
If I require services, prescriptions, or referrals beyond the primary care services available at Bucknell Student Health,
I shall assume the financial responsibility or negotiate satisfactory arrangements with the caregiver.
I understand that my contacts with Bucknell Student Health are held in confidence, but that confidentiality may be broken if my life or
that of another person is in danger.
I have attached a copy, front and back, of all health insurance cards.

Signature of Student_____________________________________________________________________________Date _________________________

Signature of parent/guardian_____________________________________________________________________ Date _________________________

(Required if student is under age 18 and not a high school graduate)
 PART III IMMUNIZATION RECORDS PHYSICIAN AND/OR STUDENT
If the immunization requirements are not met, the student will NOT be permitted to obtain their dorm room key.
Please record dates (month/day/year) below and also include a copy of vaccine records from your medical provider.

NAME
Last First Middle

D.O.B. ________/_________/_________
Month Day Year

REQUIRED IMMUNIZATIONS 1st Dose 2nd Dose 3rd Dose Booster

Date Date Date Date
1. Hepatitis B A 3-shot series is required. First of 3 must have been
given prior to enrollment at Bucknell. A blood test report showing
immunity is acceptable. M D Y M D Y M D Y

2. MMR (Measles/Mumps/Rubella) Two (2) doses after age 12 months,

given at least 28 days apart, and since 1981. Blood test reports indicating
immunity are acceptable.
M D Y M D Y
3. MENINGITIS Please check the statement that applies and sign:

_____ I have received the meningitis vaccine (Serogroup A,C,Y, W135) (Menactra, Menveo or Menomune since August 2014.
Vaccine Date _______________.

_____ I have read and understand the enclosed information about meningitis, and I decline the A,C,Y, W135 meningitis
vaccine or meningitis booster vaccine at this time. I understand that if I decide in the future that I want the vaccine, I can
receive it at Bucknell Student Health.

__________________________________________________________________________________________________________
Date Students Signature or Parents Signature if student is under age 18 or not yet graduated from high school

4. Polio (OPV or IPV) Basic series of three doses and last

booster (at least one year following completion of basic
series) and after age four. M D Y M D Y M D Y M D Y M D Y

5. TDAP (Tetanus/Diphtheria/Pertussis) Vaccine since August 2007

M D Y
6. Varicella (Chicken Pox) Two doses required*
*First dose must be given after 12 months of age M D Y M D Y
or History of having the disease, vaccine, or blood test report indicating
immunity by providing laboratory report is acceptable.
History of Disease date M D Y

OTHER IMMUNIZATIONS RECEIVED (not required): 1st Dose Date 2nd Dose Date 3rd Dose Date
Hepatitis A
HPV (Human Papillomavirus Vaccine
Meningitis - Serogroup B (New Vaccine):
Bexsero
Trumenba
Pneumococcal:
Typhoid Oral
Typhoid IM
Other:

TUBERCULOSIS SCREENING SEE SEPARATE FORM

 PART IV PHYSICAL EXAMINATION PHYSICIAN
Physical examination acceptable only if done within one (1) year prior to your first day of class at Bucknell
Attachments will not be accepted. Please use our form.

To the examining physician: Please review the students history and complete Parts IV & V. Please comment on all positive answers.

NAME_____________________________________________________________________________________________ BIRTH GENDER

Last First Middle Male ________
Female ______
BP _____________________ PULSE ____________________ HT ___________ WT____________ BMI ____________
Intersex _______

D.O.B. ________/_________/_________ PREFERRED PRONOUN

Month Day Year He ________

She ________
Other ________
Current medications, dosages and frequencies: No_______Yes______ Please list: _______________________________________________
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
Allergies to medication: No_______Yes______ Please list:
Allergies to food or environment: No_______Yes______ Please list:
Are there abnormalities of the following systems? Describe fully.

No Yes Comments (use additional sheet if needed)

1. Head, Eyes, Ears, Nose or Throat
2. Respiratory
3. Cardiovascular
4. Gastrointestinal
6. Genitourinary
7. Musculoskeletal
8. Metabolic/Endocrine
9. Neurologic
10. Concussion (if yes, how many?)
11.Skin
____________________________________________________________________________________________________________________________

Has the patient ever been diagnosed for any psychiatric or mental health condition? No_______ Yes______ Explain: ________________
____________________________________________________________________________________________________________________________
Has the patient ever been diagnosed with ADD/ADHD? No_______ Yes______
Is there a history of eating disorders? No_______ Yes______ Explain: __________________________________________________________
____________________________________________________________________________________________________________________________
General comments/recommendations: _________________________________________________________________________________________
____________________________________________________________________________________________________________________________

I certify that to the best of my knowledge the information provided on PART IV of this form is true and complete. _______
Initial

Date_________________________ Providers Signature______________________________________________________________________________

Address_______________________________________________________________________________________________________________________
Street_ City State/Zip

Telephone: (_________)__________________________________________________________________________________________________________

Fax: (__________)______________________________________________________
For Providers Stamp
 Bucknell Student Health
Tuberculosis (TB) Screening Questionnaire
PART V
PAGE 1 TO BE COMPLETED BY STUDENT AND REVIEWED BY MEDICAL PROVIDER.

Student Name: ______________________________________________________________________ DOB _____/_____/_____

(PLEASE PRINT) Last Name First Name M.I.

1. H
 ave you had a previous positive TB Skin Test No Yes
2. Have you had a previous positive IGRA Blood Test? No Yes

3. Have you ever had close contact with persons known or suspected to have active TB disease? No Yes
 ere you born in one of the countries listed below that have a high incidence of active TB disease?
4. W No Yes
(If yes, please CIRCLE the country, below)

Afghanistan Republic Guam Malawi Portugal Thailand

Algeria Chad Guatemala Malaysia Qatar The former
Angola China Guinea Maldives Republic of Korea Yugoslav Republic
Argentina Colombia Guinea-Bissau Mali Republic of of Macedonia
Armenia Comoros Guyana Marshall Islands Moldova Timor-Leste
Azerbaijan Congo Haiti Mauritania Romania Togo
Bahrain Cte dIvoire Honduras Mauritius Russian Federation Tunisia
Bangladesh Croatia India (Federated States Rwanda Turkey
Belarus Democratic Peoples Indonesia of) Micronesia Saint Vincent and Turkmenistan
Belize Republic of Korea Iraq Mongolia the Grenadines Tuvalu
Benin Democratic Japan Morocco Sao Tome and Uganda
Bhutan Republic of the Kazakhstan Mozambique Principe Ukraine
Bolivia Congo Kenya Myanmar Senegal United Republic of
(Plurinational State Djibouti Kiribati Namibia Seychelles Tanzania
of) Bosnia and Dominican Republic Kuwait Nepal Sierra Leone Uruguay
Herzegovina Ecuador Kyrgyzstan Nicaragua Singapore Uzbekistan
Botswana El Salvador Lao Peoples Niger Solomon Islands Vanuatu
Brazil Equatorial Guinea Democratic Nigeria Somalia Bolivarian Republic
Brunei Darussalam Eritrea Republic Pakistan South Africa of Venezuela
Bulgaria Estonia Latvia Palau Sri Lanka Viet Nam
Burkina Faso Ethiopia Lesotho Panama Sudan Yemen
Burundi Fiji Liberia Papua New Guinea Suriname Zambia
Cambodia Gabon Libyan Arab Paraguay Swaziland Zimbabwe
Cameroon Gambia Jamahiriya Peru Syrian Arab
Cape Verde Georgia Lithuania Philippines Republic
Central African Ghana Madagascar Poland Tajikistan

5. Have you had frequent or prolonged visits* (more than 4 weeks) to one or more of the countries listed above with a high prevalence of TB
disease? (If yes, CIRCLE the countries, above) No Yes

 ave you been a volunteer or employee of a hospital, nursing home, or health clinic?
6. H No Yes

 ave you been a resident, employee, or volunteer at high-risk congregate settings (e.g., correctional facilities, long-term care facilities
7. H
and homeless shelters)? No Yes

If the answer is YES to any of the above questions, Bucknell University requires that your Health Care Provider complete Part V Page 2

If the answer to all of the above questions is NO and you were not born or traveled to a country listed above, no further testing or action
is required and you do not need to have your Health Care Provider complete Part V, Page 2.

* The significance of the travel exposure should be discussed with a health care provider and evaluated.
PART V Bucknell Student Health Required Tuberculosis (TB) Screening
PAGE 2 TO BE COMPLETED ONLY IF STUDENT ANSWERED YES TO ANY OF THE QUESTIONS ON PART V PAGE 1

Student Name: ______________________________________________________________________ DOB _____/_____/_____

(PLEASE PRINT) Last Name First Name M.I.

MEDICAL PRACTITIONER:
Screening must be done within 12 months of the first day of classes.
A student who has any positive risk factors must be tested for TB infection if there is no written documentation of a previous positive
tuberculin skin test (TST) or positive Interferon gamma release assay (IGRA) (e.g. T-Spot, Quantiferon Gold and completed treatment).
Previous BCG Immunization does not change TB screening requirements.

TB Symptom Check Does the student have signs or symptoms of active pulmonary tuberculosis disease? No Yes

Cough (especially if lasting for 3 weeks longer)

with or without sputum production
Coughing up blood (hemoptysis) Unexplained weight loss
Chest pain Night sweats
Loss of appetite Fever

REQUIRED
Tuberculin Skin Test (TST)**
**www.cdc.gov/tb/publications/factsheets/testing/
skintesting.htm Interferon Gamma Release Assay (IGRA)
OR
Date Given: ____/____/____ Date Read: ____/____/____ Date Obtained: ____/____/____ (QFT-GIT, T-Spot)
Result: ________ mm of induration Result: negative___ positive___ indeterminate___
**Interpretation: positive____ negative____ borderline___ (T-Spot only) *Enclose copy of Lab Report
If no induration write 0

IF POSITIVE

Chest x-ray (Required if TST or IGRA is positive)

Date Obtained: ____/____/____
Result: normal ____ abnormal ____ *Enclose copy of Results

Medication _______________________________________
Provide proof of treatment given for positive TB testing: Date Treatment Started ______________________________
Date Treatment Completed ____________________________

Health care provider (M.D., D.O., P.A., N.P., R.N., school health professional, health official) verifying the above must sign below.

Provider Signature __________________________________________________ Title ___________________ Date ______________

Address _________________________________________________________ Phone ___________________ Fax _______________

 BUCKNELL STUDENT HEALTH
INSURANCE INFORMATION

Bucknell University requires all full-time students to have adequate health insurance that covers them every day of their higher education.
International students are automatically enrolled in the Bucknell Student Health Insurance Plan and should disregard this page.

International Student: Please check box.

All DOMESTIC STUDENTS are required to enroll or waive the Bucknell Student Health Insurance plan online. This form is not a waiver.
Postcards will be mailed in early summer with instructions regarding the waiver/enrollment process.

BIRTH GENDER
Student Name: ______________________________________________________________________ Male ________
(PLEASE PRINT) Last Name First Name M.I. Female ______
Intersex _______
BU I.D. _________________________
PREFERRED PRONOUN
He ________
DOB _____/_____/_____
She ________
Other ________

PARENT/GUARDIAN
Subscriber Information
Subscribers Name: ______________________________________________________________ DOB ______/_______/_______

Gender ____________________________

Relationship to Student: circle one Parent Guardian Other ____________________________

Insurance Information
Name of Insurance Company: _________________________________________________________________________________

Insurance Claims Address: __________________________________ City:______________________ State:______ Zip:__________

Insurance ID Number: ____________________________________________ Group Number: ______________________________

Does your insurance cover out of area non-emergent care? No Yes

Does your insurance have out of network benefits? No Yes

Is your insurance carrier contracted with Evangelical Hospital? No Yes

Is your insurance carrier contracted with Geisinger Medical Center? No Yes

Please place copies of the front and back of your insurance card below.
FRONT OF INSURANCE CARD BACK OF INSURANCE CARD

*Please provide copies of any additional health insurance coverage.

 MENINGITIS INFORMATION

College students are at increased risk for meningococcal disease, a potentially fatal bacterial
infection commonly referred to as meningitis. In fact, first-year students living in residence halls
are found to have a six-fold increased risk for the disease. The American College Health
Association recommends that college students, particularly first-year students living in university
housing, learn more about meningitis and vaccination. At least 70% of all cases of
meningococcal disease in college students are vaccine preventable.

On July 28, 2002, the Pennsylvania Governor signed legislation (Senate Bill 955) which requires
that all students residing in university housing either have the ACY & W135 (Menactra,
Menveo, Menomune) vaccine or sign a declination statement after review of written information
concerning the benefits of receiving the ACY & W135 meningitis vaccine.

The Meningitis B specific vaccine (Bexsero, Trumenba) is not a part of the 2002 legislation.
Although this vaccine is not required, it is a recommended vaccine.

What is meningococcal meningitis? Meningitis is rare. But when it strikes, this potentially
fatal bacterial disease can lead to swelling of membranes surrounding the brain and spinal
column as well as severe and permanent disabilities, such as hearing loss, brain damage,
seizures, limb amputation, and even death.

How is it spread? Meningococcal meningitis is spread through the air via respiratory
secretions or close contact with an infected person. This can include coughing, sneezing,
kissing or sharing items such as utensils, cigarettes and drinking glasses.

What are the symptoms? Symptoms of meningococcal meningitis often resemble influenza
and can include high fever, severe headache, stiff neck, rash, nausea, vomiting, lethargy,
and confusion.

Who is at risk? Certain college students, particularly first-year students who live in residence
halls, have been found to have an increased risk for meningococcal meningitis.

Can the chance of contracting meningitis be reduced? Yes. Safe and effective vaccines
are available; one is to protect against Groups A, C, Y, and W-135 and the other protects
against Group B.

To learn more about meningitis and the vaccine, visit Bucknell Student Health or call 570-577-
1401. Information is also available on:

o The Centers for Disease Control and Prevention (CDC) website,

www.cdc.gov/vaccines/vpd-vac/mening/faqs-parents-adolescent-vaccine.html

o The American College Health Association website, www.acha.org